Monday, July 14, 2014

Interest in pain is on the rise at the US National Institutes of Health (NIH), said Nora Volkow, chief of the National Institute on Drug Abuse, welcoming participants to the 9th Annual NIH Pain Consortium Symposium, held May 28-29, 2014, in Bethesda, US. Volkow noted a significant increase in research funding at the NIH for chronic pain conditions, which amounted to $400 million in 2014, up from $279 million in 2008. That is still just about 1 percent of the entire NIH pie, but in an era of shrinking budgets overall, that is no small progress.

The increase follows the 2010 Affordable Care Act (aka Obamacare), which mandated a hard look at the state of pain education, care, and research. That legislation led to the 2011 report from the Institutes of Medicine on the public health impact of pain (see PRF related story and commentary).

For those who want to know where that money and other federal funds are going, the NIH recently announced the launch of a database of all the federal grants related to pain (see press release and news coverage). The Interagency Pain Research Portfolio is a publicly accessible, searchable resource that for the first time collects information on all federal research, including efforts by the NIH, the Centers for Disease Control, the Department of Defense, the Food and Drug Administration, and others in one place.The database reflects the Pain Consortium's mission to enhance pain research and promote collaboration across government agencies.

Volkow also announced that on September 29-30, 2014, the NIH Office of Disease Prevention will sponsor a workshop on the role of opioids in treating chronic pain. Prescription opioid misuse, addiction, and overdose deaths have grabbed the attention of physicians, patients, the media, and policy makers, but data that would support the proper use of these drugs for chronic pain are severely limited. The workshop will tackle the scientific issues around opioid use for chronic pain. Registration will open in June. For more information, see 2014 NIH Pathways to Prevention workshop on The Role of Opioids in the Treatment of Chronic Pain.

The theme of this year's symposium was biological and psychological factors that contribute to chronic pain. Over one and a half days, speakers discussed comorbid factors including depression, sleep disturbances, and inflammation. Summaries of selected talks on pain and depression are presented here; Part 2 deals with pain and sleep. In addition, an archived webcast of the entire meeting is available on the NIH website (view Day 1 and Day 2). The complete meeting agenda is here.

Sunday, July 13, 2014

LONDON — IN 1926, Virginia Woolf published an essay on pain, "On Being Ill." Isn't it extraordinary, she observed, that pain does not rank with "love, battle and jealousy" among the most important themes in literature. She lamented the "poverty of the language of pain." Every schoolgirl who falls in love "has Shakespeare, Donne, Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry."

Where are the novels or epic poems devoted to typhoid, pneumonia or toothaches, Woolf wondered? Instead, the person in pain is forced to "coin words himself, and, taking his pain in one hand, and a lump of pure sound in the other (as perhaps the inhabitants of Babel did in the beginning), so to crush them together that a brand new word in the end drops out."

The difficulty in talking about painful sensations forces people to draw on metaphors, analogies and metonymies when attempting to communicate their suffering to others. Woolf — writing nearly a century after the popularization of ether, the first anesthetic — was perhaps too pessimistic about the creativity of sufferers. Take lower back pain, the single leading cause of disability worldwide. In the 1950s, one sufferer of back pain said that it felt like "a raging toothache — sometimes like something is moving or crawling down my legs." Half a century later, one person confessed that "my back hurt so bad I felt like I had a large grapefruit down about the curve of the back."

Woolf would not have been impressed perhaps by claims that backs hurt like a toothache or a grapefruit, but she was right to recognize that people in pain seek both to describe their suffering and to give meaning to it.

Some descriptions of pain have been consistent over time. It is frequently said to resemble a burning fire, a biting cat, a stabbing knife. Others arise as a result of specific innovations. In the 19th century, electricity and new weapons provided vivid analogies. From the 1860s, people increasingly spoke about pain as a mechanical monster. In the words of the physician Valentine Mott, writing in 1862, the pain of neuralgia was like "a powerful engine when the director turns some little key, and the monster is at once aroused, and plunges along the pathway, screaming and breathing forth flames." It was "like electric shocks in both legs" or "a lyddite shell," as one author observed in 1900, just four years after the introduction of that explosive into the British Army.

In earlier centuries, pain was more likely to be assigned a spiritual force. It was a result of sin, a guide to virtuous behavior, a stimulus to personal development or a means of salvation. As Lady Darcy Maxwell, a prominent Methodist, wrote in her diary in 1779, her severe "bodily pain" enabled her to truly "enjoy greater nearness to God, more sensible comfort, and a considerable increase of hungering and thirsting after righteousness."

The invention of effective anesthetics dealt a serious blow to the doctrine that pain had a spiritual function. If suffering could be sidestepped, belief in its divine provenance could be jettisoned. In the words of the author of "The Function of Physical Pain: Anaesthetics," published in 1871, now that pain had been "made optional" by anesthetics, it was necessary to revise "the theories of the purposes of bodily pain hitherto held by moralists." A 1935 Lancet article went further: pain was not even a sign by nature that something had gone wrong since it persisted long after "its value as a warning signal is past."

Stripped of its mysticism and its virtuous solicitations, pain was emptied of positive value. Rather than being passively endured, pain became an "enemy" to be fought and ultimately defeated. The introduction of effective relief made submission to pain perverse rather than praiseworthy.

A parallel shift changed the way doctors and other people responded to suffering. When Virginia Woolf lamented the difficulties in communicating pain, she was implicitly criticizing 20th-century medicine. In earlier periods, doctors regarded pain stories as crucial in enabling them to make an accurate diagnosis. But within a century, clinical attitudes had radically changed. Elaborate pain narratives became shameful, indicative of malingering, "bad patients."

And patients internalize this — I know I did. A few years ago, I lay in a hospital bed writhing with pain after a major operation. I remember clutching the morphine button. It didn't seem to be working, and yet I was hesitant to tell the nurse, in case she thought I was a complainer. I didn't want to "bother" her.

THIS is not to imply that physicians became less caring of their patients. Rather, what constituted a caring response changed. The "men of feeling" of the 18th century, who approached patients with hearts swollen with compassion, represent a very different conception of the display of sympathy from that of contemporary "men (and women) of science."

This valorization of detachment has gone too far, however. People in chronic pain experience their suffering not as contained and isolated in their bodies, but in interaction with other people in their environments. When I was in the hospital, I told a visiting friend that my pain was "beyond language," only to have him remind me that I had been speaking about my suffering for the past hour. Perhaps, he mildly remarked, the problem is not that people in pain cannot communicate, but that witnesses to their pain refuse to hear. I was so struck by his observation that I forgot how much pain I was experiencing. For a few moments, his empathy overcame my suffering.

We have made great strides in making patients more comfortable over the last few centuries. We may no longer believe that pain is sent by God to test us; and we may no longer need lengthy descriptions of pain to arrive at diagnoses. But pain will always be with us, and by listening closely to the stories patients tell us about their pain, we can gain hints about the nature of their suffering and the best way we can provide succor. This is why the clinical sciences need disciplines like history and the medical humanities. By learning how people in the past coped with painful ailments, we can find new ways of living with and through pain.

Joanna Bourke is a professor of history at Birkbeck College and the author of "The Story of Pain: From Prayer to Painkillers."

Thursday, July 03, 2014

There's no getting around the fact that the abuse of prescription painkillers is a huge problem in the U.S. Prescription drug overdoses now kill more people each year than car crashes.

But the overdose risks vary quite a bit depending on where in the country you live. One reason is that how often doctors prescribed the drugs, such as Percocet, Vicodin and generic opioids, varies widely by state.

The Centers for Disease Control and Prevention analyzed a commercial database of drug prescriptions looking for patterns. Nationwide, there were 82.5 prescriptions written for opioid painkillers for every 100 Americans in 2012.

But the rates were much higher in some southern states. In Alabama, which led the country, there were 143 painkiller prescriptions for every 100 people in 2012. There were 11 other states where each adult, on average, got a least one painkiller prescription that year, including Tennessee, West Virginia and Kentucky.

CDC Director Dr. Thomas Frieden told reporters that officials don't think the high rates of prescribing in some states are because people living there have more pain. "This is an epidemic that was largely caused by improper prescribing practices," he said during a media briefing.

Wednesday, July 02, 2014

A widely used method of treating a common cause of back and leg pain — steroid injections for spinal stenosis — may provide little benefit for many patients, according to a new study that experts said should make doctors and patients think twice about the treatment.

Hundreds of thousands of injections are given for stenosis each year in the United States, experts say, costing hundreds of millions of dollars.

But the study, the largest randomized trial evaluating the treatment, found that patients receiving a standard stenosis injection — which combine a steroid and a local anesthetic — had no less pain and virtually no greater function after six weeks than patients injected with anesthetic alone. The research, involving 400 patients at 16 sites, was published Wednesday in The New England Journal of Medicine.

"Certainly there are more injections than actually should happen," said Dr. Gunnar Andersson, the chairman emeritus of orthopedic surgery at Rush University Medical Center in Chicago, who was not involved in the research. "It's sort of become the thing you do. You see this abnormality on the M.R.I. and the patient complains, and immediately, you send the patient for an epidural injection."

Some people can still benefit from injections, he said, but now physicians "will be more cautious" and patients should ask, "Should I really do this?' "

Mostly, steroid injections are safe, carrying small risks of infection, headaches and sleeplessness. But in April, the Food and Drug Administration warned that they may, in rare cases, cause blindness, stroke, paralysis or death, noting that injections have not been F.D.A.-approved for back pain and their effectiveness has "not been established."